Anyone whose child uses insulin has no doubt been warned of the dangers of hypoglycemia (low blood sugar) and the need to treat it promptly. Mild hypoglycemia can cause a person to feel uncomfortable and can interfere with his normal functioning. Severe hypoglycemia can cause seizure, loss of consciousness, and coma. To prevent severe hypoglycemia, most people with diabetes are advised to treat for hypoglycemia — by ingesting some carbohydrate — when their blood sugar level is 70 mg/dl or lower. At bedtime or during the night, treatment is recommended when blood sugar is below 80 mg/dl.

Regular blood sugar monitoring can help your child avoid hypoglycemia, and so can paying attention to how he feels. Any symptoms of hypoglycemia should prompt you or him to check his blood sugar level and treat for hypoglycemia if necessary.

Not treating for hypoglycemia when blood sugar is low can have some serious consequences, among them severe hypoglycemia and, over time, the development of hypoglycemia unawareness. A person with hypoglycemia unawareness either can no longer recognize his lows or his body no longer exhibits the early warning symptoms of low blood sugar. As a result, he may develop severe hypoglycemia with no warning, possibly with disastrous results. Hypoglycemia unawareness can happen in children and adults, but it is both preventable and treatable.

Clueing in to signs and symptoms

Typical symptoms of hypoglycemia include sweating, shaking, weakness, having a headache, dizziness, and hunger. Hypoglycemia can also cause emotional symptoms such as irritability or, in some cases, giddiness. In young children, signs of low blood sugar may include crying, lethargy, pallor, glassy eyes, sleepiness, or a lack of coordination. Generally, a child will exhibit the same symptoms each time he has low blood sugar.

Since infants and very young children cannot identify signs of hypoglycemia or verbalize their symptoms to their caregivers, it’s important for parents and caregivers to notice these signs and act accordingly. Although they may be unaware of a symptom’s significance, some toddlers will verbalize symptoms by saying, for example, “I want juice” or “I’m hungry.” A preschooler may say he feels tired or that his stomach or legs feel funny. By about age six, most children can be expected to recognize symptoms of low blood sugar, understand that what they are feeling is related to low blood sugar, and understand that they need to take some action to feel better.

If your child does not verbalize any symptoms when he has low blood sugar, you can help him start to recognize symptoms by asking if he noticed any different or funny feeling just before you checked his blood sugar after a low has occurred. This sort of discussion can help even small children make the connection between their feelings and low blood sugar and can reinforce the importance of their saying something when they have symptoms.

While each person generally has the same symptoms each time he has low blood sugar, it’s still possible to occasionally have other symptoms. For example, nightmares, restless sleep, slow reaction time, and numbness around the mouth can be unusual signs of low blood sugar. Even doing poorly in school can be a sign of undetected hypoglycemia.

Mark, a junior high school student, had always done well in math, but suddenly he was struggling and his grades were slipping — even though he was putting in as much effort as he always did. His diabetes educator suggested that he check his blood sugar level for several days just before the math class. To his surprise, he found that he was low before class three days in a row, but he hadn’t noticed any of his usual symptoms at these times. Once his insulin dose was adjusted to correct the lows, his grades improved, and the experience served as a reminder that blood sugar can be low with no symptoms or with only very subtle symptoms that are easy to ignore.

But a symptom of hypoglycemia doesn’t have to be unusual to go unnoticed. Even when children experience their usual symptoms, they may not notice them if they are very involved in an activity. Children also sometimes ignore the signs and symptoms of low blood sugar so they can continue with their chosen activity, or they may not speak up because they feel too embarrassed to let someone know that they are low. This sometimes happens when they are with people they do not know very well or are at school. The trouble is, if they ignore the low too long, it can turn into a severe low, resulting in loss of consciousness or seizure. And if they ignore even mild lows too frequently, they can develop hypoglycemia unawareness.

Preventing hypoglycemia

When a person has frequent episodes of hypoglycemia, his body becomes accustomed to being low, and he no longer experiences symptoms of hypoglycemia at the same blood glucose level. In other words, he develops hypoglycemia unawareness. The first step toward preventing hypoglycemia unawareness, therefore, is to prevent even mild episodes of hypoglycemia.

For parents of young children, prevention efforts include explaining the importance of letting an adult know quickly about any signs or symptoms of low blood sugar. It may be necessary to repeat this information more than once to reinforce it. Parents of older children and teens may also need to remind their children of the importance of treating low blood sugar quickly, since diabetes may not come at the top of a child’s or teen’s list of priorities.

One of the most important tools for preventing low blood sugar is frequent blood sugar monitoring. Most diabetes professionals recommend monitoring a child’s blood sugar a minimum of four times a day — before each meal and at bedtime. In addition, checking before, during, and after exercise is important to see how exercise affects a child’s blood sugar level. It may be necessary to add a snack before or after exercise or alter a child’s insulin doses on the days he exercises to prevent hypoglycemia.

Who checks a child’s blood sugar level — parents, another caregiver, or the child himself — will depend on a child’s age and maturity level, among other things. Even if a child can check his own blood sugar level, it works best if parents remain involved, offer emotional support, help with insulin adjustments and other tasks when needed, and generally make sure blood sugar monitoring gets done.

For some children, middle-of-the-night blood sugar monitoring is recommended in addition to regular daytime monitoring. If a child has a history of severe low blood sugar during the night, it may be advisable to check blood sugar levels at midnight and at 3 AM routinely once a week. This is a challenging task for parents, but it can help a lot to see patterns and to determine whether treatment adjustments are working. It is also a good idea to check nighttime blood sugar levels after a day of heavy exercise or physical activity, because a child may have delayed hypoglycemia several hours after exercise has ended. Middle-of-the-night blood sugar levels should also be checked if your child is low at bedtime. Rechecking allows you to see whether treatment of the bedtime low (with a snack) was sufficient.

Teens who are learning to drive should be instructed (and reminded) about another important time to check their blood sugar: before they get behind the wheel of a car. Since most teens value the freedom that having a driver’s license represents, reminding them that their license may be revoked if they fail to practice safe driving may help this important lesson sink in.

Another strategy to help prevent hypoglycemia is to keep meal and insulin times consistent, with no more than half an hour of difference for insulin injections and mealtimes from one day to the next. This may be less important for children who use an insulin pump (since a bolus can be delayed until food is ready to be eaten) or inject insulin glargine (brand names Lantus and Basaglar), which has no peak. But sticking to a meal schedule makes good, common sense for other reasons, including avoiding getting too hungry and then getting cranky or overeating when the meal finally takes place. It is also usually recommended that meals have about the same amount of carbohydrate from day to day to help with blood sugar control.

Learning how to make adjustments to insulin doses is another important part of maintaining optimal blood sugar control and preventing hypoglycemia. Adjustments may be needed at mealtimes if, for example, a child refuses to eat, a high-fat meal such as pizza is served, or a child was very active earlier in the day. It may be necessary to lower a morning dose of medium-acting insulin if, for example, a late-afternoon sports event is scheduled. If you are unsure when and how to adjust your child’s insulin doses, consult your doctor or diabetes educator.

Treating hypoglycemia

Because of the importance of treating even mild hypoglycemia quickly, all children with diabetes should have a readily available source of glucose with them at all times, and parents (or caregivers) and children alike should know how to treat lows. The recommended steps are as follows:

Check blood sugar level with a meter.

If it is 70 mg/dl or lower, consume 15 grams of carbohydrate, preferably a source of carbohydrate with little or no fat or fiber. Easily portable sources of carbohydrate include glucose tablets or glucose gel, LifeSavers, small (4-ounce) juice boxes, and raisins. Beverages such as orange juice, regular soda, and nonfat milk may also be used.

Wait about 15 minutes, then check the blood sugar level with the meter again. If it is still low (under 70 mg/dl), consume another 15 grams of carbohydrate. (A child planning to engage in physical activity should consume another 15 grams of carbohydrate if his blood sugar is still below 80 mg/dl.)

Wait another 15 minutes, then check again.

If the next meal is more than half an hour away, another 15 grams of carbohydrate should be eaten to prevent blood sugar from falling again.

If a child is having symptoms of low blood sugar but cannot verify it with his meter, he or his caregiver should assume he is low and treat accordingly. However, if a child feels low but according to his blood glucose meter is not low, he should not consume any carbohydrate but should check again in 15 minutes. As long as symptoms continue, he should recheck his blood sugar every 15 minutes but only treat if his blood sugar has dropped below 70 mg/dl. Sometimes, a falling blood sugar level will produce symptoms of low blood sugar even if the blood sugar level never goes below 70 mg/dl.

Keep in mind that these are general recommendations that may be individualized by your child’s diabetes team. You may be advised to treat your child for hypoglycemia at a higher blood glucose level, for example, or to administer more than 15 grams of carbohydrate if his blood sugar level is below a certain level.

How and when to use glucagon

If a child cannot safely swallow or chew, passes out, or has a seizure because of low blood sugar, it will be necessary to use glucagon to raise his blood sugar. Glucagon is a hormone produced in the pancreas that helps to maintain blood sugar levels by causing the release of glucose from the liver. It can also be given by injection to a person with severe hypoglycemia who is unable to consume a source of carbohydrate to his raise blood sugar level. Glucagon rapidly increases a person’s blood sugar, generally within 5 to 15 minutes. If a person does not respond within 15 minutes, emergency help should be summoned.

Even if you have been instructed on how to use glucagon, it is a good idea to review how to mix and give it periodically, especially because as your child grows, the dose will change. The following are the recommended doses for glucagon based on age:

0.25 cc for children under 2 years

0.50 cc for children 2 to 5 years

1.0 cc for children older than 5 years

Glucagon is only available by prescription, and a kit should be kept at school and at home. The kit includes a prefilled syringe and a vial of powdered glucagon. Place all of the diluent (the liquid in the prefilled syringe) into the vial, mix until the glucagon is dissolved, then draw out the dose according to your child’s age. Glucagon usually expires after one year, so a new kit is needed yearly. Instead of just throwing out expired kits, practice mixing and drawing it up so you will be well trained when or if glucagon is ever needed.

Glucagon should be given based on a child’s symptoms, not his blood sugar level. It’s possible for a child to have a seizure or pass out when his blood sugar is around 50 mg/dl one time but to seem fine on another occasion when his blood sugar is closer to 30 mg/dl. No matter what his blood sugar level, do not try to give anything by mouth if your child is having a seizure or is unconscious, because he is at risk of inhaling or choking on the food or liquid. Inject glucagon instead. On the other hand, if your child’s blood glucose meter says 22 mg/dl but he is able to drink juice, give him the juice.

Even though glucagon raises blood sugar rapidly, it should not used routinely to treat low blood sugar in children capable of eating or drinking or in situations where parents are having a hard time getting juice into their child. If glucagon is given too frequently, it can lose its effectiveness.

If you have to give glucagon, make sure to contact your child’s diabetes team afterward. They will want to adjust your child’s insulin doses and talk through the days’ events prior to the severe low to see if there’s anything that can be done differently next time to prevent it from happening again. Your child may experience nausea and vomiting after receiving glucagon. If he does, you will need to lower his insulin doses and follow his sick-day guidelines until he has recovered.

Dealing with hypoglycemia unawareness

Hypoglycemia unawareness is best prevented, but if your child develops it, there are steps that can be taken to help him regain his usual feelings of low blood sugar. Most likely, his diabetes team will recommend adjusting his target blood glucose range to a higher level for a period of weeks. During this time, it will be more important than ever to avoid any episodes of hypoglycemia. To do this, he or you will need to check his blood sugar level more than the minimum of four times a day to catch undetected lows, and nighttime checks may need to be done routinely.

Hypoglycemia unawareness can be scary, but with persistence and teamwork, it can be reversed and prevented.

Karen Kelly and Amy Gilliland are pediatric diabetes educators at the Children’s Hospital of Pittsburgh in Pittsburgh, Pennsylvania.

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